Physicians suffer from "moral injury"

"If I Betray These Words

By Wendy Dean, with Simon Talbot

(Steerforth, 291 pages, $29)

'Thou must be like a promontory of the sea," the Roman emperor Marcus Aurelius wrote in "Meditations," "against which, though the waves beat continually, yet it both itself stands and about it are those swelling waves stilled and quieted."

Though he intended these words to describe the practitioner of Stoicism, they also define the ideal disposition of a doctor. As the chaos of the hospital reigns, the physician tunes it out and focuses on helping the patient.

Alas, this paradigm seems more at home in a bygone era than in our current medical system. Burnout now consumes American physicians, who are overworked, nonautonomous and adrift without help.

Such is the crisis facing physicians, according to the psychiatrist Wendy Dean and the hand surgeon Simon Talbot, co-founders of Moral Injury of Healthcare, a nonprofit focusing on distress in the healthcare workforce. In their new book, "If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First," they state that today's physicians are "seeing more patients, in less time, with fewer support staff," and are "required to use technology that interfere[s] with rather than facilitate[s] care." As a result, our healers feel exhausted, cynical, alienated and ineffective. However, the authors argue, "burnout" is a misnomer -- it suggests that physicians lack resiliency. They claim physicians suffer from "moral injury" instead. This places the blame on the system, not the physicians.

Drs. Dean and Talbot appropriately fret about the scope of moral injury. Ten percent of doctors have thought about or attempted suicide. One in five U.S. healthcare workers have left the profession since 2020 and close to half of healthcare workers plan to leave their current jobs by 2025. Almost 50% of U.S. physicians experience burnout and there was a dramatic increase in burnout among U.S. physicians between 2020 and 2021. As a result of moral injury, physicians experience poorer physical and mental health, patients suffer from poorer health outcomes, and the medical system loses around $4.6 billion yearly.

The authors illustrate the ill effects of moral injury on individual physicans through a series of riveting and poignant vignettes. One particularly troubling chapter tells the story of Jay Neufeld, a pediatric rehabilitation specialist taking care of disabled children. Neufeld worked for St. Luke's Hospital and Children's Specialty Center in Boise, Idaho. To help keep the institution solvent, hospital administrators shortened his appointments and increased patient volume. As the authors describe, "when he overstayed his scheduled time with a patient, assistants would interrupt him and say, 'Dr. Neufeld, your twenty minutes are up.' " Then one of his colleagues quit and Neufeld was the only physician left in his group. His request for more support went unanswered. When his contract came up for renewal, he faced a 30% salary cut. Subsequently, when the hospital's lack of physician coverage nearly led to the death of a patient, Neufeld further pressed his supervisors. But it was in vain. Trapped, he eventually took his own life.

How did this happen? Each chapter and story emphasizes a similar conclusion: "No matter how [physicians] respond, they are all victims of a profit-generating machine that has taken over healthcare." Profit and nonprofit hospitals, "motivated largely by revenue," cut staff, increase physician work hours, hijack physician autonomy and silence any dissent with threats of termination. Caught between the oaths they took as medical students and the crushing pressures of corporate healthcare, doctors suffer moral injury.

While the authors identify an important concern -- that current profit-seeking behavior stymies physicians and patients -- such au courant criticisms of capitalism are incomplete in explaining moral injury. Profit motives in medicine have existed for decades and will likely always exist to a certain degree. In 1894 an editorial in the journal Medical Record argued that doctors saw hospital growth "critically, not to say coldly," and resented the motive of hospitals to "get as much out of them with as little return as possible."

Today, surveys of physicians provide a more comprehensive story. They identify other factors, some of which are mentioned by Drs. Dean and Talbot, as sources of moral injury: increased bureaucracy, lack of respect from staff, lack of respect from patients, and burgeoning government regulations.

Not all of this relates to corporate greed; for instance, bureaucracy is always a side effect of government regulation. Indeed, our modern medical system now paradoxically combines the worst excesses of socialism (bureaucracy) and capitalism (greed). This contradictory yet sinewy co-existence is ultimately responsible for physician burnout. And it can only exist in a cultural environment confused about medicine's purpose.

If a physician labors only to see and please as many patients as possible, then patients, hospital staff and hospital CEOs will treat physicians as service personnel, profit-generators and "providers." If we think of doctors as algorithm-checking assembly workers, then providers belong in a bureaucracy befitting such a role. However, medicine aims to heal the individual patient, an endeavor that requires negotiation, discussion, time and care within a hospital or clinic room. Our laws and our culture ought to drive medicine toward that goal, not distract from it. If we recognize the health of the patient as medicine's purpose we necessarily treat the doctor-patient relationship as an end that every aspect of the system serves. Only this will attenuate bureaucracy, greed and moral injury.

"If I Betray These Words" ably humanizes modern, troubled physicians and rightly recognizes an important cause of their suffering. But if we want to make our doctors promontories of the ocean, stilling and quieting the swelling waves as we heal, then we must look much deeper than the corporate enterprise taking advantage of a profession lost at sea.

---

Dr. Rothstein, a neurologist and fellow in bioethics and American democracy at the Ethics and Public Policy Center in Washington, D.C., hosts the podcast "Searching for Medicine's Soul."" [1]

1. First, Do No Harm
Rothstein, Aaron.  Wall Street Journal, Eastern edition; New York, N.Y. [New York, N.Y]. 04 Apr 2023: A.17.

Turtingame pasaulyje pensininkų gyvenimas tapo daug ilgesnis

"PER pastarąją savaitę Prancūzijoje sustiprėjo protestai prieš vyriausybės pensijų reformas. Kovo 24 d., miniai padegus Bordo rotušės fasadą, prezidentas Emmanuelis Macronas atidėjo keturių dienų valstybinį Didžiosios Britanijos monarcho vizitą. 

 

Prancūzijai protestai nėra svetimi, tačiau Macrono sprendimas priverstinai padidinti pensinį amžių nuo 62 iki 64 metų sukėlė ypatingą įtūžį.

 

     Visos turtingos šalys, turinčios gerovės valstybes, iš tikrųjų turės priimti panašius nepopuliarius sprendimus. Mažesnio gimimų skaičiaus ir ilgesnio gyvenimo derinys reiškia, kad senatvės priklausomybės santykis – 65 metų ir vyresnių žmonių ir 20–64 metų amžiaus žmonių santykis – turėtų padidėti nuo vieno iš penkių 1990 m. iki vieno iš dviejų iki 2050 m. EBPO, daugiausia turtingų šalių klube. Ir laikas, kurį žmonės praleidžia, išėję į pensiją, per pastaruosius 50 metų padidėjo.

 

     1970 m. vyrai vidutiniškai išėjo į pensiją, būdami 66 metų ir galėjo tikėtis gyventi dar 12 metų. 

 

2020 m. jie išėjo į pensiją, sulaukę 64 metų ir jų laukė 20 metų. 

 

Visų pirma prancūzų vyrai išeina į pensiją ilgiausiam laikui – vidutiniškai apie 25 metus, dvigubai daugiau, nei ankstesnės kartos. 

 

Priešingai, nors jų gyvenimo trukmė, išėjus į pensiją, per tą patį laikotarpį taip pat padvigubėjo, šiandien Meksikos vyrai pensijoje praleidžia 16 metų.

 

     Kaip vyriausybės reformuoja pensijų sistemas, susidūrusios su neišvengiama demografine krize, nesukeldamos maišto? Maždaug 22 EBPO šalys taiko „automatinius koregavimo mechanizmus“, kurie, pavyzdžiui, susieja gyvenimo trukmę su įstatymų nustatytu pensiniu amžiumi arba pensijų išmokas susieja su dirbančių gyventojų skaičiumi. EBPO rekomenduoja naudoti šias priemones, kad pensijos nepakenktų vyriausybei, senstant gyventojams, taip pat sumažinti politines pensijų reformų išlaidas – išlaidas, kurias Macronas buvo pasirengęs padengti, galbūt, todėl, kad po antrosios kadencijos jis negali būti perrinktas prezidentu.

 

     Didžioji Britanija, priešingai, pastaraisiais metais padidino valstybinį pensinį amžių be didelių rūpesčių. Prancūzai turi daugiau prarasti: valstybinės pensijos sudaro dosnius 60% vidutinio galutinio asmens uždarbio Prancūzijoje, o Didžiojoje Britanijoje jos sudaro tik 20%, o privačios pensijos suteikia papildomų išmokų. 

 

Nuo 1940 m. iki 2010 m. Didžiosios Britanijos valstybinis pensinis amžius buvo 60 metų moterims ir 65 metai vyrams. Nuo tada moterų pensinis amžius buvo sulygintas su vyrų, o dabar abu pakelti iki 66 metų. Bus dar du padidinimai: iki 2027 m. – iki 67, o 2046 m. – iki 68. 2014 m. priimti teisės aktai dabar įpareigoja pensijų ministrą kas šešerius metus skelbti apžvalgas; kita – gegužės mėnesį.

 

     Tačiau net ir Didžiojoje Britanijoje ne viskas paprasta. Vyriausybė tikisi, kad pensinis amžius gali būti padidintas iki 68 metų, tačiau Didžiosios Britanijos gyvenimo trukmė pastaraisiais metais sumažėjo, todėl jai gali būti sunkiau tai padaryti. Didžioji Britanija nėra viena. 20 iš 38 EBPO šalių teisės aktai įpareigoja per ateinančius dešimtmečius padidinti pensinį amžių; tačiau dėl šlubuojančios gyvenimo trukmės tokie planai gali būti daug mažiau priimtini." [1]

 

1. "Retirement has become much longer across the rich world." The Economist, 27 Mar. 2023, p. NA.

Retirement has become much longer across the rich world.

"OVER THE past week protests in France against the government's pension reforms have intensified. On March 24th, after a mob set fire to the façade of Bordeaux's town hall, Emmanuel Macron, the president, postponed a four-day state visit by Britain's monarch, King Charles III. France is no stranger to protests. But Mr Macron's decision to force through an increase in the pension age from 62 to 64 years has aroused particular ire.

All rich countries with welfare states will, in fact, need to make similarly unpopular choices. The combination of fewer births and longer lives means that the old-age dependency ratio—the proportion of people aged 65 and older to those aged between 20 and 64—is expected to rise from one in five in 1990 to one in two by 2050 across the OECD, a club of mostly rich countries. And the time people spend in retirement has shot up in the past 50 years.

In 1970 men, on average, retired at 66 and could expect to live another 12 years. In 2020 they retired at 64 and had 20 years ahead of them. French men, in particular, have some of the lengthiest retirements—some 25 years on average, double that of the previous generation (see chart). By contrast, although their life expectancy at retirement has also doubled over the same period, Mexican men today spend 16 years in retirement.

Faced with an inevitable demographic crunch, how do governments reform pension systems without facing a revolt? Some 22 OECD countries employ "automatic adjustment mechanisms" which, for example, link life expectancy to statutory retirement age, or tie pension benefits to the size of the working population. The OECD recommends employing these tools to prevent pensions from crippling governments as populations age, while also reducing the political cost of pension reforms—a cost that Mr Macron was willing to bear, perhaps, because he cannot be re-elected after his second term as president.

Britain, by contrast, has in recent years raised the state pension age with little fuss. The French have more to lose: state pensions account for a generous 60% of an average individual's final earnings in France, whereas in Britain they account for just 20%, with private pensions providing further benefits. From the 1940s to 2010 Britain's state pension age was 60 for women and 65 for men. Since then, the pension age for women has been equalised with men's, and both have now been raised to 66. Two further increases will follow: to 67 by 2027, and to 68 in 2046. Legislation passed in 2014 now compels the pensions minister to publish reviews every six years; the next one is due in May.

Yet even in Britain it is not all plain sailing. The government is hoping it might raise the pension age to 68 sooner, but British life expectancy has flatlined in recent years, which may make it harder for it to do so. Britain is not alone. Legislation in 20 of 38 OECD countries mandates an increase in the retirement age over the coming decades; but faltering life expectancy could make such plans much less palatable.” [1]

1. "Retirement has become much longer across the rich world." The Economist, 27 Mar. 2023, p. NA.